What are massive transfusion protocols and when are they required?

Updated: Apr 16, 2019
  • Author: Linda L Maerz, MD, FACS, FCCM; Chief Editor: Emmanuel C Besa, MD  more...
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The initial evaluation of the critically injured trauma patient in the trauma bay deserves special mention.  It is imperative to rapidly identify patients who will require an MTP. The ABC (Assessment of Blood Consumption) score predicts the need for massive transfusion.  Four dichotomous parameters are easily assessed at the bedside.  The presence of any one parameter contributes one point to the total score, with a possible score ranging from 0 to 4.  The four parameters include penetrating mechanism (0 = no; 1 = yes); emergency department systolic blood pressure ≤ 90 mm Hg (0 = no; 1 = yes); emergency department heart rate ≥ 120 beats/minute (0 = no; 1 = yes); and positive abdominal sonogram (0 = no; 1 = yes).  A score of 2 is considered positive to predict the need for massive transfusion.  The negative predictive value is 97%, indicating that less than 5% of patients who require massive transfusion will be missed utilizing this scoring system. [25, 26]

Massive transfusion protocols provide a fixed ratio of PRBCs to plasma to platelets. The optimal component ratios have undergone evolution over the course of the past few years. The Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study published in 2013 demonstrated that early transfusion of plasma (within minutes of arrival in the trauma bay) resulted in improved 6-hour survival. [27]  Subsequently, the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial published in 2015 compared administration of plasma, platelets, and PRBCs in a 1:1:1 ratio compared with a 1:1:2 ratio in severely injured patients with major bleeding.  There were no significant differences in mortality at 24 hours or 30 days. However, more patients in the 1:1:1 group achieved hemostasis, and fewer died due to exsanguination by 24 hours.  There was greater transfusion of plasma and platelets in the 1:1:1 group, but no other safety differences were identified. [28]   


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